Classification of alcohol and drug problems

ClassifiCation and EpidEmiology

Classification of alcohol and drug problemsEmily finch

sarah Welch

Abstractsystems of classifying alcohol and drug problems have developed

through the disease model of the 19th century, which allows categorical

diagnosis and facilitated the 12-step approach to behavioural models

and to socioeconomic models where substance use is seen as part of

the environment in which an individual functions. dsm and iCd classified

drug and alcohol use separately in their early versions, although they are

now subject to the same criteria and both systems make a distinction

between dependant and non-dependant use. dsm-iV and iCd-10 classify

dependence as a cluster of cognitive, behavioural and physiological

systems applicable across all substances. the criteria are broadly toler-

ance and withdrawal, impaired control and compulsion and salience and

continued use despite harm. dependence symptoms, substance-related

problems and consumption form separate but related axes. Both dsm-iV

and iCd-10 contain categories of abuse and harmful use respectively for

substance users who do not meet the criteria for dependence. iCd-10

has a greater emphasis on the physical and psychological consequences

of substance abuse. a substantial body of work on the validity of the de-

pendence syndrome has generally found the dependence abuse model

to be useful across the range of substances, although for cannabis the

there are problems defining the withdrawal syndrome. Recent work to

define dsm-V may change classification systems. other forms of typol-

ogy which are clinically useful also exist; for instance, the distinction

between injecting and non-injecting drug users, and systems that detect

substance-related problems rather than diagnostic criteria.

Keywords abuse; dependence; dsm-iV; harmful use; iCd-10

Emily Finch MD MRCPsych is a Consultant Psychiatrist and visiting Senior

Lecturer at the South London and Maudsley NHS Trust and the Institute

of Psychiatry, UK, and has clinical responsibility for the North Southwark

community drug services as the Deputy Clinical Director. She is the

National Treatment Agency Clinical team leader. Research interests

include the outcome of treatment for opiate users, dual diagnosis, and

coercive treatment. She lecturers and tutors on the MSc in clinical and

public health of addiction. Conflicts of interest: none declared.

Sarah Welch DPhil MRCPsych is a Consultant Psychiatrist in Substance

Misuse for the Gloucestershire Partnership NHS Trust, UK. She

qualified from Cambridge and Oxford Universities. She studied for

her doctorate in Oxford and trained in psychiatry at the Bethlem and

Maudsley Hospitals. She has held two consultant posts in substance

misuse, one in the London Borough of Lambeth, and her current post

in a contrasting rural area. She has a special interest in psychiatric

comorbidity. Conflicts of interest: none declared.

psyCHiatRy 5:12 42

The development of classification systems

There is a spectrum of substance use behaviours, and over the past century observers have taken various different approaches in understanding and describing them.

Disease model – as early as the 1870s the concept of alcohol-ism as a disease was emerging but it was finally well described by Jellinek, a US physician, in the 1940s. Indeed, Alcoholics Anonymous (AA) continues to use the disease model in its 12-step approach and it is an integral part of the organization’s philoso-phy. The disease model allows individuals with substance-related problems to be diagnosed categorically and subsequently treated on the basis of the signs and symptoms they exhibit.

Behavioural model – another view is of substance misuse as learned behaviour: an individual has learned to use the sub-stance in the context of the society and culture in which he or she lives. This results in a more dimensional approach than the disease model and implies that cognitive–behavioural techniques may be taught to help an individual ‘unlearn’ substance-using behaviour.1

Socioeconomic model – sociologists have seen substance use as a product of the social and economic environment in which an individual finds himself. In the late 19th century, social hygien-ists identified a high prevalence of alcohol abuse among poorer people and sought to reduce it by education, resulting in the rise of the temperance movement.2,3 Since then, diagnostic systems that fail to take into account the social and cultural dimensions of substance misuse problems have been criticized.

DSM and ICD classificationEarly classification systems viewed drug and alcohol use sep-arately; indeed, DSM-I (published in 1952) classified alcoholism as one aspect of sociopathic personality disorder. The depen-dence syndrome was first proposed for alcohol use4 but was later applied to different substances (Table 1). The clinical descrip-tion by Edwards and Gross gave equal weight to physical, psychological and behavioural factors such as: • impaired control over substance use • continued use despite harm • withdrawal symptoms • a way of life centred around the substance.

The dependence concept

• allows a non-judgemental approach

• focuses on treatment of the drink or drug problem

• predicts outcome

• is associated with higher consumption levels

• is associated with higher levels of substance-related

problems

• indicates need for more intensive treatment (i.e. medically

assisted detoxification)

• indicates need for abstinence (compared with controlled

drinking)

• is flexible and describes a variety of clinical features

• is applicable to many different substances

Table 1

3 © 2006 published by Elsevier ltd.


By the time ICD-9 and DSM-III were published (1978 and 1980, respectively), drug and alcohol dependence were subject to the same criteria and there was a distinction between depen-dent and non-dependent use.5 In the latest versions (ICD-10 (1992) and DSM-IV (1994)), there are few differences between the classification systems for both dependence and abuse (see Tables 2 and 3).6,7

Dependence: core concepts

The dependence syndrome is a cluster of cognitive, behavioural and physiological symptoms, which are described in both DSM-IV and ICD-10 (see Table 2). The two systems are similar in that all criteria are given the same weight and none are essential for the diagnosis. Both require that three criteria are met over a period of 12 months. A diagnosis of dependence can be applied to all classes of substance, including: • alcohol • opioids • cocaine and other stimulants (e.g. amphetamines) • benzodiazepines • hallucinogens • nicotine. The same criteria can used for all substances but some will be less relevant to certain substances or even not apply at

psyCHiatRy 5:12 42

all; for example, withdrawal symptoms are not applicable for hallucinogens.

Tolerance and withdrawalDependent individuals usually give an account of needing increasing amounts of the substance over time to produce the desired effect. This is especially seen in those abusing alcohol, opioids and stimulants, although there is substantial individual variation. Tolerance and withdrawal are both manifestations of a neuroadaptive state that develops in response to continu-ous and repeated exposure to the psychoactive substance. The development of tolerance and withdrawal is also affected by the environment in which the substance is taken, as demonstrated by substance users experiencing withdrawal symptoms when returning to a location where they have previously taken drugs.

Impaired control and compulsionSubstance users have difficulties setting limits on their use. This is often associated with unsuccessful attempts to cut down or give up the substance, as well as a persistent desire to stop using it.

Salience and continued use despite harmSalience refers to the fact that individuals give the substance a higher priority than other interests or obligations. They will often

ICD-10 and DSM-IV classifications of the dependence syndrome

ICD-10 DSM-IV

Evidence of tolerance such that increased doses of the

psychoactive substance are required in order to achieve

effects originally produced by lower doses

tolerance as defined by either of the following:

• need for markedly increased amounts of the substance to achieve

intoxication or desired effect

• markedly diminished effect with continued use of the same amount

of substance

a physiological withdrawal state when substance use has ceased

or been reduced, as evidenced by:

• the characteristic withdrawal syndrome for the substance, or

• use of the same (or a closely related) substance with the

intention of relieving or avoiding withdrawal symptoms

Withdrawal as manifested by either of the following:

• the characteristic withdrawal syndrome for the substance

• the same (or closely related) substance is taken to relieve or avoid

withdrawal symptoms

a strong desire or sense of compulsion to take the substance no equivalent criterion

no equivalent criterion there is a persistent desire or unsuccessful efforts to cut down or

control substance use

difficulties in controlling substance-taking behaviour in terms

of its onset, termination or levels of use

the substance is often taken in larger amounts or over a longer

period than was intended

progressive neglect of alternative pleasures or interests because

of psychoactive substance use

important social, occupational or recreational activities are given up or

reduced because of substance use

increased amount of time necessary to obtain or take the

substance or recover from its effects

a great deal of time is spent in activities necessary to obtain the

substance, use the substance or recover from its effects

persisting with substance use despite clear evidence of overtly

harmful consequences. Efforts should be made to determine

that the user was actually, or could be expected to be, aware

of the nature and extent of the harm

the substance use is continued despite knowledge of having a

persistent or recurrent physical and psychological problem likely to

have been caused or exacerbated by the substance

Table 2



describe previous hobbies or interests that they have stopped doing since increasing their substance use. The criterion of continued use despite harmful consequences can be applied only if the person is aware of the causal relationship between the substance use and the resulting harm.

The relationship between dependence, consumption and problems

Dependence symptoms, substance-related problems and con-sumption form separate but related axes. However, the relation-ship between them may not be a simple one; for example, one problem drinker may have high levels of daily consumption, dependence symptoms and few alcohol-related problems, while another may binge-drink large amounts of alcohol at weekends only, have few dependence symptoms yet have serious alcohol-related problems, such as violence when drunk.

Abuse and harmful use: core concepts

‘Substance abuse’ (DSM-IV) and ‘harmful use’ (ICD-10) describe substance users who have problems related to their substance use but who do not meet the criteria for dependence (see Table 3). The two diagnostic systems differ substantially. • DSM-IV emphasizes the negative social consequences of the substance use. • ICD-10 specifically excludes socially negative consequences and emphasizes physical and mental consequences.

The result is that ICD-10 harmful use is a more socially stable syndrome that can exist across different cultures. An individual who is drinking heavily and is socially stable but develops liver disease may fulfil criteria for harmful use but not abuse, while a cocaine user arrested after causing a car crash may fulfil criteria for abuse but not harmful use.

ICD-10 and DSM-IV criteria for harmful use and substance abuse

ICD-10 criteria for harmful use

a pattern of psychoactive substance abuse that is causing

damage to health, either physical or mental. the diagnosis

requires that actual damage should have been caused to

the mental or physical health of the user. socially negative

consequences, or the disapproval of others are not in

themselves evidence of harmful use

DSM-IV criteria for substance abuse

• Recurrent substance use resulting in a failure to fulfil major

role obligations at work, school or home

• Recurrent substance abuse in situations in which it is

physically hazardous

• Recurrent substance-related legal problems

• Continued substance use despite having persistent or

recurrent social or interpersonal problems caused or

exacerbated by the effects of the substance

Table 3

psyCHiatRy 5:12 42

Validity of the dependence syndrome

As the early development of the concept of the dependence syndrome focused on alcohol, it is not surprising that the pres-ent definitions of dependence sometimes seem to ‘fit’ alcohol better than some other commonly misused substances. There has been relatively little controversy regarding the use of this framework for opioid use, given the readily observed increase in tolerance to opioids among regular users and the characteristic physiological signs of withdrawal. Such features are also clearly recognizable in long-term users of benzodiazepines. However, the relevance of the concept of dependence to drugs such as cocaine, amphetamines, cannabis and nicotine has been less certain.

Studies examining the content validity of the classificatory systems have often focused on treatment samples with extreme levels of symptomatology, and have been complicated by the effects of polydrug use. However, a large study of alcohol, opi-oid, cocaine and cannabis users conducted by the World Health Organization (WHO) in 12 countries,8 using both treatment and non-treatment settings, found the dependence and abuse con-structs to be broadly generalizable across all four categories of substance. The study supported the organization of criteria into two diagnostic categories (dependence and abuse) for alcohol, opioids and cannabis, but found that cocaine users better fitted a unidimensional model. This study also showed that within some user populations, specific criteria played a greater or lesser role in defining the latent construct. For example, the experience of withdrawal played a stronger role in defining dependence among opioid users than among users of the other substances; experien-cing increased tolerance and using more than they intended were prominent criteria among cocaine users. In practice, different features of the syndrome may therefore carry different ‘weight’ for different substances.

The WHO study did not address classification of nicotine-use disorders. However, a separate investigation on a smaller sample of daily smokers also found that a two-factor model best fitted the observed data, though the two factors were described as ‘general dependence’ and ‘failed cessation’.9

Recent research on long-term cannabis use has provided further support for the validity of a dependence syndrome as applied to cannabis users,10,11 although the definition of a clear withdrawal syndrome remains undetermined.12

DSM-V is now being planned. As part of that process consid-eration is being given to changes such as the reintroduction of the word ‘addiction’ and the addition of a dimensional element to the classification of substance use disorders.13,14

Other forms of classification

As well as the two main international systems of classification (ICD-10 and DSM-IV) there are other typologies, both formal and informal, which are used in research and clinical settings to describe and attempt to understand problems relating to sub-stance misuse. For example, a distinction is often made between injecting drug users and those who do not inject. This distinction can be made separately from the concepts of dependence and abuse, and is of practical significance since injecting drug users are at risk of a wide range of physical complications unrelated to



drug use by other routes. Other approaches concentrate more on classifying problems related to substance use, and are useful in planning and prioritizing interventions. This has led to the devel-opment of instruments such as the Alcohol Problems Question-naire,15,16 which assess problems rather than diagnostic criteria. Such instruments can be used separately from or in conjunction with instruments that assess dependence. ◆

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